Monday, February 16, 2015

Twenty-five years ago, when a doctor named Robert Ross was the deputy health commissioner of Philadelphia, a measles epidemic swept the country. Until this year’s outbreak, which started at Disneyland and has so far sickened more than a hundred people, the 1989-91 epidemic was the most alarming that the United States had seen since 1963, when the measles vaccine was introduced. Nationwide, there were more than fifty-five thousand cases and eleven thousand hospitalizations; a hundred and twenty-three people died. Most of those infected were unimmunized babies and toddlers, predominantly poor and minority kids living in cities. Ross thought that the blame for the outbreak could be placed partly on poverty and partly on crack cocaine, which was “making a lot of families forget how to raise children.”

One cluster of kids was getting sick, though, not because their parents lacked the wherewithal to have them immunized but because the parents, members of the Faith Tabernacle congregation, did not believe in immunization. When children in the congregation started dying—ultimately, five did—Ross and his colleagues began going door to door, telling parents that kids whose lives were in danger could be hospitalized by court order. In one house, Ross found an ashen-faced girl of eight or nine who could barely breathe. He got her to the hospital and, when he saw her the next day in the I.C.U., had no doubt that taking her from her home had saved her life. The memory of those who weren’t saved still troubles Ross: “These were kids who had no business being lowered into the ground. And I’ve never gotten over it.”

The epidemic spurred the creation, in 1993, of a federal program, Vaccines for Children, which subsidized shots for children who were uninsured or on Medicaid. Immunization rates soared. Then a new skepticism about vaccination settled in—this time, more often than not, among affluent parents who were drawn to holistic living and were dubious about medical authority. An infamous 1998 study in The Lancet, which claimed that the rising incidence of autism was linked to vaccinations, was particularly influential with some of those parents—even though the data were found to be falsified and the author’s medical license was revoked. Another theory, tying autism to thimerosal, a preservative added to vaccines, has also been debunked. Since 2001, thimerosal has been used only in the flu vaccine—and there is a thimerosal-free alternative—but the incidence of autism continues to rise.

Nevertheless, the skepticism endured, and one result has been the decisive return of infectious diseases. First, it was whooping cough: in 2012, more than forty-eight thousand cases and twenty deaths were reported to the Centers for Disease Control, the greatest number since 1955. Now it’s measles. Both illnesses pose an especially serious threat to babies (infants under a year old cannot be vaccinated) and to people who cannot be vaccinated for medical reasons—if their immune systems are weakened by cancer drugs, for instance—and the complications are costly to treat. As many as one in every twenty children with measles will develop pneumonia; one in every thousand will develop encephalitis, which can leave a child deaf or brain-damaged. In addition, measles is airborne and extremely contagious; virus transmitted by a sneeze on the Dumbo ride or in the doctor’s-office waiting room can still infect people an hour later. That is why, in the case of measles, a community generally needs more than ninety per cent of its members to be immunized against the virus in order to protect those who can’t be. “Herd immunity” doesn’t work unless most of the herd is vaccinated.

What does work is legislation. The highest vaccination rate in the country is in Mississippi, a state with an otherwise dismal set of health statistics. It allows people to opt out of vaccines only for medical reasons—not for religious or personal ones. States that make it easier not to vaccinate have higher rates of infectious diseases. California, which has seen ninety-nine cases in this epidemic, is one of nineteen states that allow people to opt out not only for religious and medical reasons but also on the basis of a loosely defined “personal belief.” In 2012, though, the state legislature passed a law requiring parents to consult with a health-care professional about vaccination before they reject it, and the opt-out rates declined slightly for the first time in years. (Washington passed a similar law and has experienced a bigger decline.) Last week, legislators in California introduced a bill to eliminate the personal-belief exemption—but that may actually be too abrupt and punitive a solution. According to some epidemiologists who study the anti-vaccine movement, it’s probably more effective to continue to enforce a regime that makes it more difficult but not impossible for parents to opt out.

What does not help at all is to treat vaccines and the diseases they prevent as partisan political matters. In 1993, when the Clinton Administration championed Vaccines for Children, it drew bipartisan support; it would have seemed bizarre to cast a measure aimed at preventing epidemics of childhood disease in ideological terms. In fact, until recently, vaccine refusal wasn’t a partisan issue—some objections came from anti-government types but many were from self-identified progressives. In the current discussion, however, conservatives have been embracing a precious individual right to shun inoculation. On Fox News, Sean Hannity declared that he wasn’t “trusting President Obama to tell me whether to vaccinate my kids.” Asked about immunization on CNN last week, Senator Rand Paul, a potential Republican candidate for President—and a doctor—painted a pointlessly terrifying scenario: “I’ve heard of many tragic cases of walking, talking, normal children who wound up with profound mental disorders after vaccines.” No doubt, he has heard such stories, but the evidence does not support them. . . .

Robert Ross believes that “doubling down on education” about infectious diseases will help the situation, but he wonders if that’s enough to “reacquaint some parents”—not to mention some elected officials—“with the dangers of these diseases.” Ross had to rely on the law and the courts to help him save children’s lives in Philadelphia. By then, the situation was dire. He worries that more children will die unnecessary deaths before reason again takes hold.